Superior-inferior Sliding Conjunctival Flap for Pterygium with a Fibrin Tissue Adhesive (Tisseel(R))

PURPOSE: To report the clinical effect of a superior-inferior sliding conjunctival flap for pterygium using fibrin tissue adhesives (Tisseel(R); Baxter Healthcare Corporation, Glendale, CA) instead of sutures. METHODS: After the primary pterygial tissue was removed from the sclera, a superior-inferior sliding conjunctival flap was created. The fibrin tissue adhesive (Tisseel(R)) was composed of two solution types: fibrinogen containing aprotinin solution and a CaCl solution containing thrombin. The two solutions with 27 G needle were applied on the bare sclera in sequence, and the conjunctival flap was attached into the bare sclera within 5 seconds. We performed this procedure with a fibrin tissue adhesive instead of sutures in three patients, and follow-up for recurrence of pterygium and postoperative complications. RESULTS: The superior-inferior sliding conjunctival flaps were attached into the bare sclera in all patients using fibrin tissue adhesives. We didn't find any significant postoperative complications such as ocular pain, epiphora, foreign body sensation, wound defect, or dehiscence. CONCLUSIONS: A superior-inferior sliding conjunctival flap constructed with fibrin tissue adhesives should be a useful management tool for the inhibition of the recurrence of pterygial.

Scleral Attachment of Extraocular Muscle using a Stitch Combined with Tissue Adhesive in Rabbits

In experimental sutureless muscle surgery with tissue adhesives, current materials have inadequate adhesive strength in the early postoperative period.We performed a modified muscle surgery using a stitch combined with Tisseel (Immuno AG, Vienna, Austria)in order to evaluate the adhesive strengh as a replacement for conventional suture techniques in muscle surgery. Thirty eyes of 15 rabbits were used.We recessed superior and inferior rectus muscles by three different methods, Tisseel only, a stitch with Tisseel, and a stitch only, in each group of 5 rabbits.Conjunctival incisions were closed with the remaining Tisseel in 7 rabbits, and with vicryl in 8 rabbits. Tensile strength of the scleral reattachment site was measured and conjunctival closure was examined by slit-lamp biomicroscopy, at intervals of 1 hour, 12 hours, 1 day, 3 days and 5 days. The strengths of a stitch with Tisseel at each interval were 83.25 +/-1 4 .0 6 gm, 137.50 +/-22.88 gm, 169.75 +/-23.95 gm, 151.50 +/-41.99 gm, and 265.50 +/- 25.01 gm, respectively.The strengths of Tisseel alone were 61.50 +/-2 0 .2 1 gm, 101.50 +/-11.00 gm, 113.25 +/-28.69 gm, 120.50 +/-18.36 gm, and 222.75 +/- 57.67 gm.They were 52.25 +/-24.85 gm, 89.50 +/-16.05 gm, 130.75 +/-21.98 gm, 1 5 3 .7 5 +/-30.35 gm, and 261.50 +/-60.47 gm at each interval in rabbits with a stitch alone. These results showed that the tensile strengths of a stitch with Tisseel were stronger than those of the other two methods up to 1 day after surgery.Even at postoperative 12 hours, the strength was more than 130 gm which was strong enough for scleral attachment.All of the conjunctival closures with Tisseel were well maintained without any complication up to 5 days, the same as vicryl sutures. In conclusion, this study revealed that muscle attachment to the sclera by a stitch with Tisseel was simpler and safer than classical sutures with reduced risk of sclera perforation.Its strong tensile strength at early postoperative days suggests that the method might be considered as an alternative method to classical reattachment using suture material and also that conjunctiva could be closed with Tisseel remnant.

Positional Changes of Reattachment Site after Superior Rectus Recession in Rabbit

In determining the effects of strabismus surgery, it is very important to know where the reattachment site of an extraocular muscle following recession procedure is located. Undercorrections or overcorrections after muscle surgery have been thought to be due to a postoperative positional changes of reattachment site along the surface of the globe. The author performed this experimental study to evaluate the amounts of changes of reattachment site after recession procedure in rabbit with 4 different methods of scleral fixation;direct suture with 6-0 vicryl, hang-back suture, application with Tisseel and Histoacryl. Superior rectus recession was performed in all 40 rabbit eyes, 10 eyes in each group. The distance from limbus to proximal end of recessed superior rectus muscle was measured on day 1, 2, 3, 5 and 7 postoperatively. Further measurements were followed at 2, 3, 4 and 8 weeks after recession procedure. The muscles were found an average of 0.4mm posterior to the intended position in direct suture group and 0.5 mmin hang-back suture group at one week postoperatively. But in the other two groups in which tissue adhesive agents, Tisseel and Histoacryl were used, the amount of displacement of the reattachment site were minimal of within 0.1 mm. From this experimental study, it is suggested that the positional changes of the reattachment site after recession procedure may influence the surgical corrective effects for strabismus.

The Effect of Fibrin Glue(Tisseel(R)) on the Filtration Surgery in Rabbits

During filtration surgery for glaucoma, the conjunctival incision site is sutured watertightly with a suture material like 10-0 nylon. However, this suture material may cause the infiltration of inflammatory cells, and the proliferation and migration of fibroblasts and collagen fibers at the junction of the conjunctiva and episclera. Subsequently, the arrangement of collagen fiber in episclera would be disrupted and the outflow of aqueous humor could be occluded. In the search for a more suitable suture material, the fibrin glue(Tisseel(R)) was introduced recently. It is claimed to be simple to use and safe, causes less damage and less inflammatory reaction than nylon. The authors used 10-0 nylon(control group) on the right eye and fibrin glue(Tisseel(R))(experimental group) on the left eye of a white rabbit's conjunctival suture. We compared and evaluated the clinical and histological effects of the suture material on the suture site as well as on the intraocular region. The results were as follows; 1. In the experimental group, conjunctival injection and chemosis were mild and disappeared rapidly. 2. The filtering bleb was macroscopically well formed and maintained from the third postoperative day in both groups, but, thereafter, it decreased in size in two cases of the control group. 3. There was no difference in the inflammatory reaction in anterior chamber in both groups postoperatively. 4. In the experimental group, there was loosening of the fibroblasts proliferation and lesser infiltration of inflammatory cells at the postoperative second and fourth week. And the arrangement of collagen fibers in episclera was intact. The above findings strongly suggest fibrin glue(Tisseel(R)) as a suture material in the filtration surgery of glaucoma is clinically promising.